Bill S6586-2013

Relates to Medicaid reviews and appeals

Provides that enrollees are not required to exhaust Medicaid appeals prior to requesting a fair hearing.






TITLE OF BILL: An act to amend the social services law and the public health law, in relation to medicaid reviews and appeals

PURPOSE OR GENERAL IDEA OF BILL: To clarify that Medicaid enrollees who have been denied services by a Medicaid managed care plan may file for a fair hearing under the Social Services Law as well as internal and external appeal under managed care laws, and are entitled to the continuation of services as usual while appeals and fair hearings proceed.

SUMMARY OF SPECIFIC PROVISIONS: The bill amends Social Services Law 22 and Public Health Law § 4403-F to assure that Medicaid enrollees do not have to exhaust internal and external appeals of managed care plan adverse determinations in order to proceed with Medicaid fair hearings. The bill amends Social Services Law § 265-a to clarify that health care services continue until the appeal(s) is resolved.

JUSTIFICATION: Medicaid recipients are increasingly moved into managed care plans subject to the managed care internal and external appeal processes. This is being used to assert that the recipients may not file for a Social Services Law fair hearing until those managed care appeals are exhausted. Unfortunately, this has the effect of depriving recipients of their longstanding right to have services continue while a fair hearing appeal is pending. This can have the effect of depriving people of health care services to which they are legally entitle.

This bill will assure that the remedies of managed care benefits appeals are cumulative to Medicaid fair hearing rights and that health care services once determined to be medically necessary are not threatened by bureaucratic delays in either appeal process.



EFFECTIVE DATE: Immediately and apply to any appeal pending at the time.


STATE OF NEW YORK ________________________________________________________________________ 6586 IN SENATE February 10, 2014 ___________
Introduced by Sen. RIVERA -- read twice and ordered printed, and when printed to be committed to the Committee on Social Services AN ACT to amend the social services law and the public health law, in relation to medicaid reviews and appeals THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM- BLY, DO ENACT AS FOLLOWS: Section 1. Section 22 of the social services law is amended by adding a new subdivision 15 to read as follows: 15. WITH RESPECT TO MEDICAL ASSISTANCE UNDER TITLE ELEVEN OF ARTICLE FIVE OF THIS CHAPTER, WHERE THE MEDICAL SERVICE AT ISSUE IS OR WOULD BE PROVIDED BY AN ENTITY SUBJECT TO ARTICLE FORTY-NINE OF THE PUBLIC HEALTH LAW OR ARTICLE FORTY-NINE OF THE INSURANCE LAW: 1. AN ENROLLEE SHALL NOT BE REQUIRED TO EXHAUST HIS OR HER REVIEW OR APPEAL REMEDIES UNDER ARTICLE FORTY-NINE OF THE PUBLIC HEALTH LAW OR ARTICLE FORTY-NINE OF THE INSURANCE LAW PRIOR TO REQUESTING A FAIR HEAR- ING UNDER THIS SECTION OR ANY OTHER STATE OR FEDERAL LAW. HOWEVER, IN AN APPROPRIATE CASE, THE HOLDING OR CONTINUING OF THE FAIR HEARING MAY BE DELAYED PENDING THE OUTCOME OF SUCH REVIEW OR APPEAL. 2. THE RIGHTS AND REMEDIES CONFERRED UNDER THOSE PROVISIONS OF THE PUBLIC HEALTH LAW OR THE INSURANCE LAW SHALL BE CUMULATIVE AND IN ADDI- TION TO AND NOT IN LIEU OF ANY OTHER RIGHTS OR REMEDIES AVAILABLE UNDER LAW. S 2. Subdivision 8 of section 365-a of the social services law, as added by section 46-a of part B of chapter 58 of the laws of 2009, is amended to read as follows: 8. When a non-governmental entity is authorized by the department pursuant to contract or subcontract to make prior authorization or prior approval determinations that may be required for any item of medical assistance, a recipient may challenge any action taken or failure to act in connection with a prior authorization or prior approval determination as if such determination were made by a government entity, and shall be entitled to the same medical assistance benefits and standards and to the same notice and procedural due process rights, including a right to a fair hearing and aid continuing pursuant to section twenty-two of this
chapter, as if the prior authorization or prior approval determination were made by a government entity, WITHOUT REGARD TO EXPIRATION OF THE PRIOR SERVICE AUTHORIZATION. S 3. Subparagraph (ii) of paragraph (a) of subdivision 7 of section 4403-f of the public health law, as amended by section 41-b of part H of chapter 59 of the laws of 2011, is amended to read as follows: (ii) Notwithstanding any inconsistent provision of the social services law to the contrary, the commissioner shall, pursuant to regulation, determine whether and the extent to which the applicable provisions of the social services law or regulations relating to approvals and author- izations of, and utilization limitations on, health and long term care services reimbursed pursuant to title XIX of the federal social security act, including, but not limited to, fiscal assessment requirements, are inconsistent with the flexibility necessary for the efficient adminis- tration of managed long term care plans and such regulations shall provide that such provisions shall not be applicable to enrollees or managed long term care plans, provided that such determinations are consistent with applicable federal law and regulation, AND SUBJECT TO THE PROVISIONS OF SUBDIVISION EIGHT OF SECTION THREE HUNDRED SIXTY-FIVE-A OF THE SOCIAL SERVICES LAW. S 4. This act shall take effect immediately and shall apply to any review or appeal under the social services law, public health law or insurance law pending at the time it becomes a law; provided, however, that the amendments to section 4403-f of the public health law made by section three of this act shall not affect the repeal of such section and shall be deemed repealed therewith.


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